Multidisciplinary management of thoracic esophageal fistula secondary to traumatic upper thoracic fracture (T3-4) with associated discitis/osteomyelitis and spinal epidural abscess: illustrative case

Abstract

Background: An esophageal fistula secondary to a traumatic upper thoracic (T3-4) fracture with resultant thoracic discitis/osteomyelitis and an epidural abscess with neurological compromise is a rare clinical entity. Early diagnosis is critical for an optimal clinical outcome avoiding grave and progressive spinal dissemination with structural instability and neurological deterioration.

Observations: The following case, not clearly described previously in the literature, highlights the clinical course and multidisciplinary approach to management including a single-stage posterior cervicothoracic (C3-T6) decompression with vertebral reconstruction with an expandable interbody cage (T2-4) and posterior cervicothoracic fusion and instrumentation (C3-T6), followed by direct esophageal fistula closure with AlloDerm and a vascularized latissimus dorsi muscle flap.

Lessons: Early diagnosis and the potential treatment of a posttraumatic esophageal fistula requires a multidisciplinary approach.

Keywords: discitis/osteomyelitis; epidural abscess; multidisciplinary management; thoracic fracture; traumatic esophageal fistula.

FIG. 1

Initial CT scans (A and B) and sagittal T2-weighted MRI scan (C) displaying “beak-like” fracture. Sagittal T1-weighted MRI scan (D) prior to laminectomy. Sagittal T1-weighted MRI scans (E and F) postlaminectomy with progressive spinal dissemination.

FIG. 2

Radiological imaging performed after a single-stage posterior cervicothoracic (C3–T6) decompression with vertebral reconstruction with an expandable interbody cage (T2–4) and posterior cervicothoracic fusion and instrumentation (C3–T6), displaying good screw and cage placement.

FIG. 3

Initial thoracic CT scan demonstrating anatomical proximity of the esophagus (star) with the vertebral fracture. The arrow indicates a prominent ventral osteophyte vertebral fracture, or “beaked” fracture. The circle indicates the trachea.

FIG. 4

Thoracic MRI scans with proximal esophageal dilatation and esophageal distortion with compression from a beaked vertebral osteophyte/fracture (arrows). Stars indicate the esophagus, and circles indicate the trachea.

FIG. 5

Sagittal (A and B) and axial (C and D) thoracic T1-weighted MRI scans with contrast displaying a periesophageal fistula/abscess (red arrows). Stars indicate the esophagus, and circles indicate the trachea.